DSM v. Freud

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is an influential work that comes up in nearly every criminal case with a mental issue. In Saturday's Wall Street Journal, Paul McHugh of Johns Hopkins U. reviewsShyness: How Normal Behavior Became a Sickness, by Christopher Lane. McHugh credits Lane with a revealing look at how the DSM-III (1980) was prepared and how it was a reaction to Freudian psychoanalysis. "He is also right in observing that the [DSM] errs by designating [shyness and] other kinds of normal human variation as mental disorders and so exaggerates the incidence of mental illness." This is, in part, a product of the DSM's "field guide" approach to mental diagnosis, identifying mental disorders with checklists of characteristics similar to those used by birdwatchers to identify birds.

McHugh parts company with Lane on where to go next. He says that Lane, a professor of literature, not psychology, has a fondness for psychoanalysis and thinks the profession should return to it. Absurd, says McHugh. "Today, Freud is deader than Elvis. Nobody investigating psychiatric disorders is dancing to Freud's tunes." Overdiagnosis is a real problem and needs to be addressed, McHugh says, but not by going backward.

Of course, the DSM and its "field guide" approach identified by Lane and McHugh are not the only reasons for diagnosing normal human variation -- both variation between people and the ups and downs of one person's life -- as mental disorders. Here are a few others:

Insurance: Some people need counseling and can benefit from it, but they can't or don't want to pay for it out of pocket. Medical insurance has been extended to mental illness, however, so a DSM diagnosis is the ticket to having one's counseling paid by the insurance company. Who does the diagnosis? The person getting paid.

SSI: The government pays cash to people with disabilities. It pays cash to parents of children with disabilities. Depression is a lot easier to fake than missing limbs. Learn the criteria from the "field guide" and relate them to a diagnostician who has no incentive to detect malingering and may have a positive incentive to go along with it. It's not like winning the lottery, but the odds are a lot better.

Special Education: "Special needs" kids produce dollars flowing down to the school district from higher levels of government. A mental disorder "causing" misbehavior is a special need. An undisciplined kid who needs to be straightened out the old-fashioned way is not.

Criminal Law: A diagnosis of a mental disorder is a mitigating circumstance for a lesser sentence, and sometimes it is an excuse for outright acquittal. For a mental health professional who thinks our law's punishments are too severe, especially capital punishment, stretching to reach a diagnosis is a way to pick up some government-paid fees while justifying the prostitution of science with the belief that it is in a good cause. A history of false diagnoses from the first three causes above is helpful for this effort.